Revamped AUC in Chronic Coronary Disease Reflect Changing Practice

The document was simplified to track closer with practical clinical decision-making, says co-chair David Winchester.

Revamped AUC in Chronic Coronary Disease Reflect Changing Practice

A panel of experts from the American College of Cardiology, the American Heart Association, and others has substantially revised appropriate use criteria (AUC) regarding detection and risk assessment in patients with known or suspected chronic coronary disease (CCD), while also streamlining their ease of use.

Published last week in the Journal of the American College of Cardiology, the report replaces the 2013 multimodality AUC for detection and risk assessment of stable ischemic heart disease (SIHD).

Writing group co-chair David E. Winchester, MD, MS (University of Florida, Gainesville), said the committee focused on making needed structural changes in the document to pare it down for busy practitioners.

“We really wanted to simplify the criteria to make them easier to use and easier to navigate,” he told TCTMD. “We also wanted to make them more reflective of day-to-day clinical practice [and] we really felt strongly that reorganizing the document around the presence or absence of symptoms is a pretty basic sort of question that most clinicians are going to face in the process of making decisions.”

The AUC document contains diagnostic and prognostic recommendations for testing in common clinical scenarios, ranking management strategies as “appropriate,” “may be appropriate,” or “rarely appropriate.” Rather than establishing a single best test for each clinical scenario, the recommendations include a range of options, with guidance on which ones may or may not be reasonable for a given scenario.

Although it does not address acute chest pain episodes, the recommendations may be applicable in inpatient settings “if the patient is not having an acute coronary syndrome and warrants evaluation for CCD,” the authors say.

Changes and Expansions for 2023

The clinical scenarios themselves represent the most-substantive changes, with the addition of recommendations for unsupervised exercise prescriptions in patients with and without known coronary disease, guidance on screening for transplant vasculopathy, and testing in new paroxysmal sustained ventricular tachycardia (VT) and atrial flutter.

Winchester said the scenario of asymptomatic patients without known atherosclerotic cardiovascular disease (ASCVD) is particularly notable in its revision.

“We really wanted to make sure that clinicians were given guidance on using not only the high-risk estimate, which has been around for quite some time, but also other risk factors that are not captured in that calculator,” he noted. Patients with prior radiation to the chest and those with chemotherapy with vasotoxicity potential have been added to the current list of risk-enhancing factors for ASCVD.

“I think the other thing that people are going to notice is less of an emphasis on invasive testing and more of an emphasis on things like calcium scoring as a strategy for understanding what somebody's risk is if you’re feeling like a test is necessary in that population.”

The other major change in this updated document is the inclusion of a “no testing” column to most of the 64 clinical scenarios. The reason, the writing group says, is to “formally acknowledge that testing may be safely deferred in some situations.”

Incorporating the “no testing” recommendation as an option has multiple potential implications, they add, including “an opportunity to engage in shared decision-making with patients, allowing personal values and preferences to weigh on the choice to perform a test.”

Another addition is the inclusion of cardio-oncology patients within the category of “other” CV conditions in asymptomatic individuals. For the patients with prior chest radiation, noninvasive testing with ECG treadmill, stress nuclear myocardial perfusion imaging, stress echo, stress cardiac magnetic resonance, coronary artery calcium (CAC), or coronary computed tomography angiography (CCTA) may be appropriate. However, no testing may also be an option.

Also noticeable in this 2023 update is a primary terminology change for the classification of angina. “Likely anginal” and “less likely anginal” now supersede “typical,” or “atypical” across the clinical scenarios. The move, said Winchester, is in step with the 2021 chest pain guidelines, which similarly ousted “atypical” as a descriptor of chest pain.

“The term atypical was one where everybody on the writing group felt that we had seen plenty of anecdotes of people using it both to upsell and to undersell a given patient's chest pain syndrome,” he added. “Basically anyone other than a white man would frequently get downplayed [by the use of] that word atypical . . . and so we felt that we should not be using it.”

According to the writing group, “likely anginal” and “less likely anginal” are equivalent to the chest pain guidelines’ use of the terms “cardiac” and “possibly cardiac.”

As a nod to closing potential gaps left by the prior AUC for CCD, the document also has added clinical scenarios for assessing graft patency before redo sternotomy, viability assessment, and management of patients with or at risk for silent ischemia.

“I would really encourage people to look at our flowchart, [and] if you compare it to the prior versions, it's much flatter, there's much less hierarchy, much fewer steps that you have to go through before you get to the table that's got the clinical scenarios that are of interest to you,” Winchester added.

Disclosures
  • Winchester reports no relevant conflicts of interest.

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